The infection prevention team at the
University of Florida Health Jacksonville (UFHJ) spearheaded multiple
organizational improvements to change culture and enhance patient safety at
their facility.

As the only level I, academic safety net
hospital in the region, UFHJ sees many of the most complex patients. “There was
a mindset that we couldn’t do much about infections because our patients are so
sick,” said Infection Prevention and Control (IPC) Director Chad Neilsen.

In 2014, the facility’s leadership
included central line-associated bloodstream infection (CLABSI) and
catheter-associated urinary tract infection (CAUTI) reductions in the
organization’s strategic goals, signaling an increased emphasis on patient
safety. An external consultant identified several key IPC challenges, including
manual, retrospective infection-data reporting and placement of the IPC
department under nursing. Shortly after, the facility shifted the department
under the hospital’s quality division and created a new IPC director position. “Our
new director provided perspective that enabled us to make key changes,” said IPC
team member Stefanie Buchanan.

These changes included real-time
electronic surveillance and leveraging other technologies –such as a root-cause
analysis tool and an app-based program for hand-hygiene surveys — that
improved feedback and helped drive timely interventions.

The IPC team used data from these systems
to determine infection priorities and create multidisciplinary committees focused
on individual HAIs. Bedside rounding on all floors helped identify gaps, which
staff shared with the committees. “Information filters to the committees in a very
fluid way, and they develop plans,” said Buchanan.

Finally, UFHJ instituted systems to
increase shared accountability. “We needed the units to understand that any single
infection can signal opportunities for hospital-wide process improvement,” said
Buchanan.

Between 2015-2018, UFHJ recorded a 74
percent reduction in CLABSI and an 86 percent reduction in CAUTI. “Celebrate
your wins along the way, and it will help maintain the motivation to change,”
said Buchanan.